Nursing Elites

1. The client had surgery one day ago. What assessment is most likely related to pain?

• A. Blood pressure of 175/90 mm Hg
• B. Respirations of 10 breaths per minute
• C. Heart rate 60 beats/minute
• D. Oxygen saturation of 97%

Correct answer: A

Rationale:

2. Which of the following clients are at an increased risk for deep vein thrombosis following a reduction and internal fixation of the hip? (Select all that apply)

• A. A client on birth control pills
• B. A client who is immobile
• C. A client on an anticoagulant
• D. A client with dementia who has been wandering

Correct answer: a

Rationale: Clients on birth control pills, immobile, and smokers are at increased risk of DVT after hip surgery.

3. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?

• A. Client will increase mobility by the time of discharge from hospital
• B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
• C. Client will increase activity tolerance by discharge from the hospital
• D. Client will remain free from falls throughout their hospital stay

Correct answer: D

Rationale:

4. What health teaching would not help an older adult avoid a musculoskeletal injury?

• A. Avoid home modification
• B. Wear a helmet when riding a bicycle
• C. Osteoporosis screening
• D. Fall prevention

Correct answer: A

Rationale: Avoiding home modifications can increase the risk of falls and injuries in older adults.

5. The nurse is planning care for a post-operative client after a total hip arthroplasty. What is the priority nursing intervention?

• A. Observe client for changes in mental status
• B. Use aseptic technique for wound care and emptying of drains
• C. Keep the client's heels off the bed
• D. Perform neurovascular assessments per protocol

Correct answer: D

Rationale:

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